Provider Demographics
NPI:1922095082
Name:NELSON, JOHN LOUIS (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
Last Name:NELSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20211 PATIO DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4338
Mailing Address - Country:US
Mailing Address - Phone:510-881-4401
Mailing Address - Fax:510-881-4423
Practice Address - Street 1:20211 PATIO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4338
Practice Address - Country:US
Practice Address - Phone:510-881-4401
Practice Address - Fax:510-881-4423
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4985T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD004985Medicare PIN
0675090001Medicare NSC
CACA121305Medicare PIN
CA410018404Medicare PIN